After 40-plus hours of surgery,
Fletcher has what he calls his 'brand-new nose.'

Multiple reconstructive operations on 23-year-old took
place over a year

By David MarchJohns Hopkins Medicine

It took only seconds for the Humvee to flip over and
crash on a highway near Camp
Bucca in southern Iraq in August 2005. The force of impact
was blunted by the body armor
protecting Senior Airman Michael Fletcher. But his gear was
not strong enough to stop the
wreck from crushing the rest of him. His left arm was gone,
and along with it a sizable chunk
of his midface, including his nose.

Fletcher, who is 23, remembers little of the
disfiguring accident that nearly killed him,
but he likes to recall shopping in January 2007 near his
home on Andrews Air Force Base in
Maryland. Nobody stared at his torn face, he said. Not
anymore, that is, because of his
"brand-new nose."

In a series of six operations over a yearlong period
that ended with removal of the last
sutures on May 2 — and that together rank as one of
the most complicated nasal
reconstructions ever performed at Johns Hopkins —
facial plastic and reconstructive surgeons
pieced together more than a dozen bits of bone, cartilage,
skin, arteries and veins to rebuild
Fletcher's nose. All materials were taken from spare or
renewable parts of his own body.

Fletcher's new nose is completely functional. He can
breathe and sneeze through it, and
his surgeons' expectations are that he will soon be
sensitive to smell and touch.

Scarring and swelling will naturally reduce for a
year, and minor sculpting and contouring
procedures will be done at an outpatient clinic, but
Fletcher's long days recuperating in the
hospital are done, said lead surgeon Patrick J. Byrne.

Aided by new advances in instrumentation by biomedical
engineers, and computer-assisted design of precision
plastics for use as templates, Byrne's team and the patient
logged
more than 40 hours in surgery, with the first operation, on
July 18, lasting eight hours. With
his wife, Yolanda, by his side the entire time, Fletcher
had more than 60 hospital checkups and
tests and needed three hospital stays, including a 16-hour
emergency operation to deal with a
wound infection.

"This soldier is fearless," said Byrne, an assistant
professor in otolaryngology-head and
neck surgery at the School of Medicine. "From the
beginning, his nasal reconstruction was not
straightforward. He had tremendous scarring all over his
face and head injuries so severe
that I did not think he would go through it. But he did not
want to wear a prosthesis. He
wanted his nose rebuilt, even if all the world was going to
see his scars.

"And there was significant risk that any transferred
tissue would not survive. It could
get infected and have to be removed, adding scar tissue and
leaving us back where we
started," he said, recalling the courage of his patient.

Hospital records show that Fletcher's new nose
involved more than 40 Johns Hopkins
clinical staff, including an anaplastologist, who helped
design the shape and look of the new
nose; several anesthesiologists; operating room nurses;
schedulers and home care assistants.
In addition, a team of surgeons from the U.S. military
initially treated Fletcher in Kuwait and
then at Walter Reed Army Medical Center, in suburban
Washington, D.C.

A Walter Reed surgeon who had trained in facial
plastic surgery at Johns Hopkins, and
who was familiar with Byrne's recent work with cancer
patients, referred Fletcher to Johns
Hopkins in January 2006 for the reconstruction.

The plan to rebuild Fletcher's nose was based on
techniques already used to help
survivors of nasal cancers resume a normal life without
disfigurement. Though rare, these
cancers are often fatal without surgery to remove tumors.
Some cases require total removal
of the nose.

Complicating Fletcher's case was the soldier's damaged
facial skeleton, which had little
bone structure to support a new nose, and a sparse network
of facial arteries to sustain the
highly vascularized nasal tissues. Arteries supplying blood
to the forehead had been slashed,
potentially compromising the suitability of the skin for
subsequent transplant to the nose. The
accident had also fractured Fletcher's skull, blinded his
left eye and widened the gap between
his eyes, something surgeons had to correct in order to
properly place the nose.

Fletcher is African-American, so surgeons were
compelled to minimize risk of scarring,
as any scar tissue would contrast sharply with his dark
skin.

Among the many procedures was the detachment of a
forehead flap of skin that now
makes up the outer skin of the new nose. The flap was first
carved in upside-down profile on
the center of his forehead, with the top portion then cut
out, turned around clockwise, and
laid over the newly rebuilt nose.

The outer skin covering was left attached for six
weeks to the center spot of the
forehead, between Fletcher's eyes, to secure its blood
supply during recovery. While attached,
the forehead flap was covered with a protective bandage to
prevent infection. Surgeons had
earlier made small incisions across the skin graft to
promote new blood vessel formation, and
to improve the covering's arterial network before
transplant.

The inside nasal components were assembled in two
operations, using skin transplanted
from his arm and neck, and bone and cartilage from his rib
and ear. One of the more complex
procedures involved transfer of soft skin from the
underside of Fletcher's arm to create an
inside nasal lining. Arteries in his neck had to be
rerouted to keep sufficient blood flowing to
this part of the nose.

Weeks before the first operation, the surgical team
fully mapped out Fletcher's interior
and exterior skull, including his nasal passage, by CT scan
and nasal endoscopy.

Unique to the Johns Hopkins approach is the use of
clear plastic molds that are custom-
made to help surgeons shape the skin flap, build up
supporting cartilage and construct the
nose. (A mesh made of different plastic is often used as an
alternative support structure in
cancer patients; sometimes left inside the body, the mesh
is resorbed — chemically broken
down and disposed of naturally, over time.)

Design and production of the nasal surgical guide
began more than three months before
Fletcher's first surgery. Anaplastologist Juan Garcia, a
medical illustrator who specializes in
facial prosthetics, met with Fletcher, and together —
using pictures of the soldier taken
before his accident as a reference — they designed
his new nose.

Garcia, an assistant professor in Art as
Applied to Medicine, also took a silicone
impression of Fletcher's midface and created a stone model
of the damaged terrain on which
his new nose would be built. Onto this base the artist
applied hot wax and sculpted a replica of
the planned nose, something he had done many times before
when making prosthetic noses,
ears and even eyes. The modeling process took more than two
hours and required dozens of
minute touch-ups.

Once fitted, the wax replica and stone model were each
scanned by a computer to
create a 3-D image needed to produce the plastic guide. The
methods for using laser scanning
and computer software necessary to produce the surgical
tool were developed by Byrne and
Garcia with a local digital imaging firm, Direct Dimensions
of Owings Mills, Md.

After making the computerized version of the surgical
guide, the 3-D image was sent to
the Berger laboratory at the U.S. Army's Aberdeen Proving
Ground, in Gunpowder, Md., for
fabrication into a plastic version. The lab specializes in
manufacturing precision plastics for
the military and private industry, including the kinds of
clear plastic molds that Byrne has
used to reconstruct noses for a half-dozen cancer
patients.

"We know that our part in his recovery is just a
single step forward," Garcia said. "But
we are grateful to have been able to help, and wish him
well. He is someone with a tremendous
amount of courage."

Fletcher's surgery was paid for by his military health
insurance plan. In addition to
Byrne and Garcia, facial plastic surgeons involved in
Fletcher's care were Chris Cote and Kofi
Boahene.